Asthma Management Handbook

Investigating new asthma-like symptoms in older adults

Recommendations

Consider the possibility of adult-onset asthma in adults of any age with dyspnoea, wheeze or cough, even older people without a history of asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

When taking a history, ask about:

  • lifetime smoking history (including exposure to environmental tobacco smoke)
  • comorbid conditions
  • new medicines or a change in the regimen
  • occupational exposure to allergens or irritants
  • new hobbies that may expose the person to new allergens or irritants.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

When investigating new respiratory symptoms that suggest asthma, perform or arrange spirometry before and 15 minutes after bronchodilator, as for younger adults.

Note: If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriate provider such as an accredited respiratory function laboratory.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Reed, 20101

Before doing spirometry, assess comorbidities and check if the person has any contraindications to spirometry. Advise patients to empty their bladder before spirometry.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If FEV1 improves after administering short-acting beta2 agonist but the response does not meet criteria for acute response to bronchodilator, repeat spirometry 6–8 weeks after a treatment trial of an inhaled corticosteroid. Compare pre-bronchodilator FEV1 with the pre-bronchodilator FEV1 reading from the previous visit.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If spirometry before and after bronchodilator demonstrates expiratory airflow limitation that is not completely reversible, consider the possibility of COPD as an alternative diagnosis or of asthma–COPD overlap, even if the person has never smoked.

Note: people with longstanding asthma can develop fixed airflow limitation that resembles COPD.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Gibson et al. 20102
  • Gibson and Simpson, 20093
  • McDonald et al. 20124
  • Abramson et al. 20125
  • Reed, 20101

More information

Asthma prevalence in older adults

An estimated 7–15% of Australians aged 65 years or over have asthma, similar to asthma prevalence in the general adult population.6 According to the latest available Australian population survey data (2011–2012),7 self-reported current asthma rates among those aged 65–74 years are 9% for men and 13% for women, and among those aged 75 years and over are 8% for men and 13% for women.

New cases of adult-onset asthma can occur at any age.2 Asthma is under-diagnosed and commonly misdiagnosed in older people.2, 6, 89, 10 The diagnosis is unrecognised in an estimated 50% of people with asthma aged over 75 years.2

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Effects of ageing on the lungs

Lung function peaks at age 20–25 years, then progressively falls throughout life.2 Age-related decrease in lung function is greater in men than in women.1

Ageing is associated with increased work of breathing, weakening of respiratory muscles, and inflammation of the airways.2

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Asthma presentation in older adults

Asthma presents with the same clinical features in older adults as in younger adults.6 However, older patients may under-report symptoms and attribute breathlessness to age or other comorbidities.2, 6

Wheeze and whistling in the chest are common (particularly in those aged over 75 years) and can be due to asthma, COPD, cardiac failure, acute bronchitis, bronchiectasis, cancer, or pulmonary embolism.2 Wheezing can also occur in obese people who do not have asthma. Approximately one-third of people over 75 years old experience breathlessness.2

As with any patient, a careful history is necessary to identify symptoms and triggers. Physical examination should include examination of upper airway and chest auscultation, and alternative causes of respiratory symptoms should be considered and investigated as indicated.

Ask about new hobbies that may expose the person to new airborne allergens or irritants (e.g. woodworking, bird-keeping or home renovation projects). Asthma that begins in late adult life is rarely immunoglobulin E (IgE)-mediated.1 However, allergic sensitisation is still common enough among older patients with respiratory symptoms to warrant allergy tests in the investigation of asthma-like symptoms11 when allergic triggers are suspected (e.g. if history suggests that symptoms worsen seasonally or in certain places, or if control not achieved despite adherence to appropriate treatment and correct inhaler technique).

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Lung function testing in older adults

More than 90% of patients with obstructive airway disease aged 65 years and over can perform an acceptable spirometry test (when staff are appropriately trained and rigorous quality control protocols are followed).2, 12, 13

Contraindications to spirometry include conditions in which increased blood pressure, intraocular pressure, intra-abdominal or intrathoracic pressure may be dangerous, such as unstable cardiovascular disease, recent myocardial infarction, recent pulmonary embolus, aneurysm, and recent cataract surgery.14 Advise patients to empty their bladder before spirometry, because the effort required may cause leaking for those with urinary incontinence.

FEV1/FVC ratio decreases with normal ageing. Reference values for forced expiratory volume in one second (FEV1) and ratio of FEV1 to forced vital capacity (FEV1/FVC) applicable to people aged up to 95 years have been developed.15 Reference values for older people are incorporated into newer spirometers. Airflow limitation should not be diagnosed based solely on the shape of the flow–volume loop.

Some degree of concavity in the expiration flow–volume curve (typical of airflow limitation) occurs as people age, even without asthma.

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Definition of variable expiratory airflow limitation

Most of the tests for variable expiratory airflow limitation are based on showing variability in FEV1. While reduced FEV1 may be seen with many other lung diseases (or due to poor spirometric technique), a reduced ratio of FEV1 to FVC indicates airflow limitation.16 Normal FEV1/FVC values derived from population studies vary,1715 but are usually greater than:17

  • 0.85 in people aged up to 19 years
  • 0.80 in people aged 20–39 years
  • 0.75 in people aged 40–59 years
  • 0.70 in people aged 60–80 years.

In children, it is less useful to define expiratory airflow limitation according to a specific cut-off for FEV1/FVC ratio, because normal values in children change considerably with age.15

Some spirometers provide predicted normal values specific to age group. If these are available, a FEV1/FVC ratio less than the lower limit of normal (i.e. less than the 5th percentile of normal population) indicates airflow limitation.

Variable expiratory airflow limitation (beyond the range seen in healthy populations) can be documented if any of the following are recorded:

  • a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from baseline for children) 10–15 minutes after administration of bronchodilator
  • clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry on separate visits)
  • a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on spirometry, or decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise challenge testing uses different criteria for exercise-induced bronchoconstriction)
  • a clinically important increase in lung function (at least 200 mL and 12% from baseline) after a trial of 4 or more weeks of treatment with an inhaled corticosteroid
  • clinically important variation in peak expiratory flow (diurnal variability of more than 10%)
  • a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway hyperresponsiveness (exercise challenge test or bronchial provocation test) measured by a respiratory function laboratory.

Notes

Patients referred to a respiratory function laboratory may be asked not to take certain medicines within a few hours to days before a spirometry visit.

A clinically important increase or decrease in lung function is defined as a change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.1816 A clinically important increase in FVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less reliable measure in primary care because FVC may vary due to factors such as variation in inspiratory volume or expiratory time.

The finding of ‘normal’ lung function during symptoms reduces the probability that a patient has asthma, but a clinically important improvement in response to bronchodilator or inhaled corticosteroid can occur in patients whose baseline value is within the predicted normal range.

The greater the variation in lung function, the more certain is the diagnosis of asthma. However, people with longstanding asthma may develop fixed airflow limitation.

Reversibility in airflow limitation may not be detected if the person is already taking a long-acting beta2 agonist or inhaled corticosteroid.

Airflow limitation can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during a severe acute infection of the respiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have a respiratory tract infection. Reduction in lung function during a respiratory tract infection with improvement in lung function after its resolution, commonly occurs in people with asthma, but can also be seen in patients with COPD or in healthy people without either asthma or COPD.19,20

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Coexisting asthma and COPD in older adults

Definition and prevalence

There is a subgroup of patients with longstanding asthma who do not demonstrate reversible airflow limitation.34 Asthma that begins later in life often shows a component of irreversible or incompletely reversible airflow limitation (also called ‘fixed airway obstruction’), due to airway remodelling and stiffening of the chest wall.1

Correspondingly, there is a subgroup of patients with COPD who demonstrate significant bronchodilator response and meet the diagnostic criteria for asthma.34

The coexistence of incompletely reversible airflow limitation (characteristic of COPD) and increased airflow variability (characteristic of asthma) is relatively common among people with respiratory symptoms aged 65 years and over, and even among those over 50 years.2, 3

Risk factors for coexisting asthma and COPD

Smoking (or exposure to smoke) is a major risk factor for COPD.5 However, the coexistence of asthma and COPD in older patients is not always due to cigarette smoking.1 In some people, COPD may develop as a complication of long-term asthma.2 Incompletely reversible airway limitation can also be unrelated either to the duration of disease or to the individual’s smoking history.1

Investigating suspected COPD in older patients

If initial spirometry shows a partial response to bronchodilator that does not meet criteria for reversible airflow limitation (increase of at least 200 mL and at least 12%), a treatment trial of an inhaled corticosteroid for 6–8 weeks can help distinguish between those with significant eosinophilic airway inflammation (who may thus show improvement in FEV1 with corticosteroid treatment) and those with ‘fixed’ airflow obstruction (who may not show any improvement in spirometry).

Note: If the patient has features of asthma, long-term inhaled corticosteroid treatment is recommended to reduce the risk of asthma flare-ups, even if the patient does not show a short-term response in FEV1.

For patients with incompletely reversible airflow limitation, a careful history will often clarify which investigation is most appropriate. Lung volume tests and diffusing capacity tests may be helpful to identify emphysema or pulmonary fibrosis. High-resolution computed tomography is useful if bronchiectasis is suspected.

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References

  1. Reed CE. Asthma in the elderly: diagnosis and management. J Allergy Clin Immunol. 2010; 126: 681-7; quiz 688-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20673985
  2. Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010; 376: 803-813. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20816547
  3. Gibson PG, Simpson JS. The overlap syndrome of asthma and COPD: what are its features and how important is it?. Thorax. 2009; 64: 728-735. Available from: http://thorax.bmj.com/content/64/8/728.full
  4. McDonald VM, Higgins I, Gibson PG. Managing older patients with coexistent asthma and chronic obstructive pulmonary disease. Drugs Aging. 2013; 30: 1-17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23229768
  5. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
  6. Cousens NE, Goeman DP, Douglass JA, Jenkins CR. The needs of older people with asthma. Aust Fam Physician. 2007; 36: 729-31. Available from: http://www.racgp.org.au/afp/200709/18551
  7. Australian Bureau of Statistics. 4364.0.55.001 – Australian Health Survey: First Results, 2011–12. Australian Bureau of Statistics, Canberra, 2012. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.001main+features12011-12
  8. Jones SC, Iverson D, Burns P, et al. Asthma and ageing: an end user's perspective--the perception and problems with the management of asthma in the elderly. Clin Exp Allergy. 2011; 41: 471-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21395876
  9. Goeman DP, Douglass JA. Optimal management of asthma in elderly patients: strategies to improve adherence to recommended interventions. Drugs Aging. 2007; 24: 381-394. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17503895
  10. Stupka E, deShazo R. Asthma in seniors: Part 1. Evidence for underdiagnosis, undertreatment, and increasing morbidity and mortality. Am J Med. 2009; 122: 6-11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19114162
  11. Scichilone N, Augugliaro G, Togias A, Bellia V. Should atopy be assessed in elderly patients with respiratory symptoms suggestive of asthma?. Expert Rev Respir Med. 2010; 4: 585-91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20923338
  12. Lehmann S, Vollset SE, Nygaard HA, Gulsvik A. Factors determining performance of bronchodilator reversibility tests in middle-aged and elderly. Respir Med. 2004; 98: 1071-1079. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15526807
  13. Bellia V, Catalano F, Pistelli R, Antonelli Incalzi R. Aging on quality of spirometry. Am J Respir Crit Care Med. 2004; 170: 100. Available from: http://www.atsjournals.org/doi/full/10.1164/ajrccm.170.1.962
  14. Cooper BG. An update on contraindications for lung function testing. Postgrad Med J. 2011; 87: 724-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21954034
  15. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J. 2012; 40: 1324-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22743675
  16. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948-968. Available from: http://erj.ersjournals.com/content/26/5/948
  17. National Heart Lung and Blood Institute (NHLBI) National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for the diagnosis and management of asthma. Full report 2007. US Department of Health and Human Services National Institutes of Health, Bethesda, 2007. Available from: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report
  18. Levy ML, Quanjer PH, Booker R, et al. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J. 2009; 18: 130-147. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19684995
  19. Collier AM, Pimmel RL, Hasselblad V, et al. Spirometric changes in normal children with upper respiratory infections. Am Rev Respir Dis. 1978; 117: 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/619724
  20. Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994; 7: 1239-1245. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7925901